UMUC Critical Reflection on Effectiveness of Psychotherapy

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The Effectiveness of Psychotherapy The Consumer Reports Study This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Martin E. P. Seligman University of Pennsylvania Consumer Reports (1995, November) published an article which concluded that patients benefited very substantially from psychotherapy, that long-term treatment did considerably better than short-term treatment, and that psychotherapy alone did not differ in effectiveness from medication plus psychotherapy. Furthermore, no specific modality of psychotherapy did better than any other for any disorder; psychologists, psychiatrists, and social workers did not differ in their effectiveness as treaters; and all did better than marriage counselors and long-term family doctoring. Patients whose length of therapy or choice of therapist was limited by insurance or managed care did worse. The methodological virtues and drawbacks of this large-scale survey are examined and contrasted with the more traditional efficacy study, in which patients are randomized into a manualized, fixed duration treatment or into control groups. I conclude that the Consumer Reports survey complements the efficacy method, and that the best features of these two methods can be combined into a more ideal method that will best provide empirical validation of psychotherapy. H ow do we find out whether psychotherapy works? To answer this, two methods have arisen: the efficacy study and the effectiveness study. An efficacy study is the more popular method. It contrasts some kind of therapy to a comparison group under well-controlled conditions. But there is much more to an efficacy study than just a control group, and such studies have become a high-paradigm endeavor with sophisticated methodology. In the ideal efficacy study, all of the following niceties are found: 1. The patients are randomly assigned to treatment and control conditions. 2. The controls are rigorous: Not only are patients included who receive no treatment at all, but placebos containing potentially therapeutic ingredients credible to both the patient and the therapist are used in order to control for such influences as rapport, expectation of gain, and sympathetic attention (dubbed nonspecifics). 3. The treatments are manualized, with highly detailed scripting of therapy made explicit. Fidelity to the manual is assessed using videotaped sessions, and wayward implementers are corrected. 4. Patients are seen for a fixed number of sessions. 5. The target outcomes are well operationalized (e.g., December 1995 • American Psychologist Copyright 1995 by the American Psychological Association. Inc. 6 months §30 E CD §•20 o This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. (8" 10 Note. N - 2, 738. Mean percentage who reported that treatment "made things a lot better" with respect to four domains: enjoying life more, personal growth and insight, self-esteem and confidence, and alleviating low moods. Those treated by psychiatrists, psychologists, social workers, marriage counselors, and physicians are segregated by treatment for more than six months versus treatment for less than six months. comes with higher credibility than studies that issue from drug houses, from either APA, from consensus conferences of the National Institute of Mental Health, or even from the halls of academe. In summary, the main methodological virtue of the CR study is its realism: It assessed the effectiveness of psychotherapy as it is actually performed in the field with the population that actually seeks it, and it is the most extensive, carefully done study to do this. This virtue is akin to the virtues of naturalistic studies using sophisticated correlational methods, in contrast to well-controlled, experimental studies. But because it is not a well-controlled, experimental study like an efficacy study, the CR study has a number of serious methodological flaws. Let us examine each of these flaws and ask to what extent they compromise the CR conclusions. Consumer Reports Study: Methodological Flaws and Rebuttals Sampling. Is there a bias such that those respondents who succeed in treatment selectively return their questionnaires? CR, not surprisingly, has gone to considerable lengths to find out if its reader's surveys have sampling bias. The annual questionnaires are lengthy and can run to 100 questions or more. Moreover, the respondents not only devote a good deal of their own time to filling these out but December 1995 • American Psychologist also pay their own postage and are not compensated. So the return rate is rather low absolutely, although the 13% return rate for this survey was normal for the annual questionnaire. But it is still possible that respondents might differ systematically from the readership as a whole. For the mental health survey (and for their annual questionnaires generally), CR conducted a "validation survey," in which postage was paid and the respondent was compensated. This resulted in a return rate of 38%, as opposed to the 13% uncompensated return rate, and there were no differences between data from the two samples. The possibility of two other kinds of sampling bias, however, is notable, particularly with respect to the remarkably good results for AA. First, since AA encourages lifetime membership, a preponderance of successes—rather than dropouts—would be more likely in the three-year time slice (e.g., "Have you had help in the last three years?"). Second, AA failures are often completely dysfunctional and thus much less likely to be reading CR and filling out extensive readers' surveys than, say, psychotherapy failures who were unsuccessfully treated for anxiety. A similar kind of sampling bias, to a lesser degree, cannot be overlooked for other kinds of treatment failures. At any rate, it is quite possible that there was a large oversampling of successful AA cases and a smaller oversampling of successful treatment for problems other than alcoholism. Could the benefits of long-term treatment be an artifact of sampling bias? Suppose that people who are doing well in treatment selectively remain in treatment, and people who are doing poorly drop out earlier. In other words, the early dropouts are mostly people who fail to improve, but later dropouts are mostly people whose problem resolves. CR disconfirmed this possibility empirically: Respondents reported not only when they left treatment but why, including leaving because their problem was resolved. The dropout rates due to the resolution of the problem were uniform across duration of treatment (less than one month = 60%; 1— 2 months = 66%; 3-6 months = 67%, 7-11 months = 67%; 12 years = 67%; over two years = 68%). A more sweeping limit on generalizability comes from the fact that the entire sample chose their treatment. To one degree or another, each person believed that psychotherapy and/or drugs would help him or her. To one degree or another, each person acknowledged that he or she had a problem and believed that the particular mental health professional seen and the particular modality of treatment chosen would help them. One cannot argue compellingly from this survey that treatment by a mental health professional would prove as helpful to troubled people who deny their problems and who do not believe in and do not choose treatment. N o control groups. The overall improvement rates were strikingly high across the entire spectrum of treatments and disorders in the CR study. The vast majority of people who were feeling very poor orfairly poor when they entered therapy made "substantial" (now feeling/air/}' good or very good) or "some" (now feeling so-so) gains. Perhaps 971 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. the best news for patients was that those with severe problems got, on average, much better. While this may be a ceiling effect, it is a ceiling effect with teeth. It means that if you have a patient with a severe disorder now, the chances are quite good that he or she will be much better within three years. But methodologically, such high rates of improvement are a yellow flag, cautioning us that global improvement over time alone, rather than with treatment or medication, may be the underlying mechanism. More generally, because there are no control groups, the CR study cannot tell us directly whether talking to sympathetic friends or merely letting time pass would have produced just as much improvement as treatment by a mental health professional. The CR survey, unfortunately, did not ask those who just talked to friends and clergy to fill out detailed questionnaires about the results. This is a serious objection, but there are internal controls which perform many of the functions of control groups. First, marriage counselors do significantly worse than psychologists, psychiatrists, and social workers, in spite of no significant differences in kind of problem, severity of problem, or duration of treatment. Marriage counselors control for many of the nonspecifics, such as therapeutic alliance, rapport, and attention, as well as for passage of time. Second, there is a dose-response curve, with more therapy yielding more improvement. The first point in the dose-response curve approximates no treatment: people who have less than one month of treatment have on average an improvement score of 201, whereas people who have over two years of treatment have an average score of 241. Third, psychotherapy does just as well as psychotherapy plus drugs for all disorders, and there is such a long history of placebo controls inferior to these drugs that one can infer that psychotherapy likely would have outperformed such controls had they been run. Fourth, family doctors do significantly worse than mental health professionals when treatment continues beyond six months. An objection might be made that since total length of time in treatment—rather than total amount of contact—is the covariate, comparing family doctors who do not see their patients weekly with mental health professionals—who see their patients once a week or more—is not fair. It is, of course, possible that if family doctors saw their patients as frequently as psychologists do, the two groups would do equally well. It was notable, however, that there were a significant number of complaints about family doctors: 22% of respondents said their doctor had not "provided emotional support"; 15% said their doctor "seemed uncomfortable discussing emotional issues"; and 18% said their doctor was "too busy to spend time talking to me." At any rate, the CR survey shows that long-term family doctoring for emotional problems—as it is actually performed in the field—is inferior to long-term treatment by a mental health professional as it is actually performed in the field. It is also relevant that the patients attributed their improvement to treatment and not time (determined by responses to "How much do you feel that treatment helped you in the following areas?"), and I conclude that the benefits of treatment are very unlikely to be caused by the mere passage of time. But I also conclude that the CR study could be improved by control groups whose members are not 972 treated by mental health professionals, matched for severity and kind of problem (but beware of the fact that random assignment will not occur). This would allow the Bayesian inference that psychotherapy works better than talking to friends, seeing an astrologer, or going to church to be made more confidently. Self-report. CR's mental health survey data, as for cars and appliances, are self-reported. Improvement, diagnosis, insurance coverage, even kind of therapist are not verified by external check. Patients can be wrong about any of these, and this is an undeniable flaw. But two things can be said in response. First, the noise self-reports introduce—inaccuracy about improvement, incorrectness about the nature of their problem, even inaccuracy about what kind of a therapist they saw—may be random rather than systematic, and therefore would not necessarily bias the study toward the results found. Self-report, in principle, can be either rosier or more dire than the report of an external observer. Since most respondents are probably more emotionally invested in psychotherapy than in their automobiles, however, it will take further research to determine whether the noise introduced by self-report about therapy is random or systematic. Second, the most important potential inaccuracy produced by self-report is inaccuracy about respondents' own emotional state before and after treatment, and inaccuracy in ratings of improvement in the specific problem, in productivity at work, and in human relationships. This is, however, an ever-present inaccuracy even with an experienced diagnostician, and the correlations between self-report and diagnosis are usually quite high (not surprising, given the common method variance). Such self-reports are the blood and guts of a clinical diagnosis. But multiple observers are always a virtue, and diagnosis by a third party would improve the survey method noticeably. Blindness. The CR survey is not double-blind, or even single-blind. The respondent rates his or her own emotional state, and knows what treatment he or she had. So it is possible that respondents exaggerate the virtues or vices of their treatment to comply with or to overthrow their hypotheses about what CR wants to find. I find this far-fetched: If nonblindness compromised readers' surveys, CR would have long ago ceased publishing them, since the readers' evaluations of other products and services are always nonblind. CR validates its data for goods and services in two ways: against manufacturers' polls and for consistency over time. Using both methods, CR has been unable to detect systematic distortions in its nonblind surveys of goods and services. Inadequate outcome measures. CR's indexes of improvement were molar. Responses like made things a lot better to the question "How much did therapy help you with the specific problems that led you to therapy?" tap into gross processes. More molecular assessment of improvement, for example, "How often have you cried in the last two weeks?" or "How many ounces of alcohol did you have yesterday?" would increase the validity of the method. Such detail would, of course, make the survey more cumbersome. A variant of this objection is that the outcome meaDecember 1995 • American Psychologist This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. sures were insensitive. This objection looms large in light of the failure to find that any modality of therapy did better than any other modality of therapy for any disorder. Perhaps if more detailed, disorder-specific measures were used, the dodo bird hypothesis would have been disconfirmed. A third variant of this objection is that the outcome measures were poorly normed. Questions like "How satisfied were you with this therapist's treatment of your problem? Completely satisfied, very satisfied, fairly well satisfied, somewhat dissatisfied, very dissatisfied, completely dissatisfied," and "How would you describe your overall emotional state? very poor. I barely managed to deal with things; fairly poor. Life was usually pretty tough for me; so-so: I had my ups and downs; quite good: I had no serious complaints; very good: Life was much the way I liked it to be" are seat-ofthe-pants items which depend almost entirely on face validity, rather than on several generations of norming. So the conclusion that 90% of those people who started off very poor or fairly poor wound up in the very good, fairly good, or so-so categories does not guarantee that they had returned to normality in any strong psychometric sense. The addition of extensively normed questionnaires like the Beck Depression Inventory would strengthen the survey method (and make it more cumbersome). Retrospective. The CR respondents reported retrospectively on their emotional states. While a one-time survey is highly cost-effective, it is necessarily retrospective. Retrospective reports are less valid than concurrent observation, although an exception is worth noting: waiting for the rosy afterglow of a newly completed therapy to dissipate, as the CR study does, may make for a more sober evaluation.The retrospective method does not allow for longitudinal observation of the same individuals for improvement across time. Thus the benefits of long-term psychotherapy are inferred by comparing different individuals' improvements crosssectionally. A prospective study would allow comparison of the same individuals' improvements over time. Retrospective observation is a flaw, but it may introduce random rather than systematic noise in the study of psychotherapy effectiveness. The distortions introduced by retrospection could go either in the rosier or more dire direction, but only further research will tell us if the distortions of retrospection are random or systematic. It is noteworthy that Consumer Reports generally uses two methods. One is the laboratory test, in which, for example, a car is crashed into a wall at five miles per hour, and damage to the bumper is measured. The other is the reader's survey. These two methods parallel the efficacy study and the effectiveness study, respectively, in many ways. If retrospection was a fatal flaw, CR would have given up the reader's survey method long ago, since reliability of used cars and satisfaction with airlines, physicians, and insurance companies depends on retrospection. Regardless, the survey method could be markedly improved by being longitudinal, in the same way as an efficacy study. Self-report and diagnosis both could be done before and after therapy, and a thorough follow-up carried out as well. But retrospective reports of emotional states will always be with us, since even in a prospective study that begins with a diagnostic interDecember 1995 • American Psychologist view, the patient retrospectively reports on his or her (presumably) less troubled emotional state before the diagnosis. Therapy junkies. Perhaps the important finding that long-term therapy does so much better than short-term therapy is an artifact of therapy "junkies," individuals so committed to therapy as a way of life that they bias the results in this direction. This is possible, but it is not an artifact. Those people who spend a long time in therapy may well be "true believers." Indeed, the long-term patients are distinct: They have more severe problems initially, are more likely to have an emotional disorder, are more likely to get medications, are more likely to see a psychiatrist, and are more likely to have psychodynamic treatment than the rest of the sample. Regardless, they are probably representative of the population served by long-term therapy. This population reports robust improvement with long-term treatment in the specific problem that got them into therapy, as well as in growth, insight, confidence, productivity at work, interpersonal relations, and enjoyment of life. Perhaps people who had two or more years of therapy are likely still to be in therapy and thus unduly loyal to their therapist. They might then be more likely to distort in a rosy direction. This seems unlikely, since a comparison of people who had over two years of treatment and then ended therapy showed the same high improvement scores as those with over two years of treatment who were still in therapy (242 and 245, respectively). Nonrandom assignment. The possibility of such biases could be reduced by random assignment of patients to treatment, but this would undermine the central virtue of the CR study—reporting on the effectiveness of psychotherapy as it is actually done in the field with those patients who actually seek it. In fact, the lack of random assignment may turn out to be the crucial ingredient in the validity of the CR method and a major flaw of the efficacy method. Many (but assuredly not all) of the problems that bring consumers into therapy have elements of what was called "wanhope" in the middle ages and is now called "demoralization." Choice and control by a patient, in and of itself, counteracts wanhope (Seligman, 1991). Random assignment of patients to a modality or to a particular therapist not only undercuts the remoralizing effects of treatment but also undercuts the nonrandom decisions of therapists in choice of modality for a particular patient. Consider, for example, the finding that drugs plus psychotherapy did no better than psychotherapy alone for any disorder (schizophrenia and bipolar depression were too rare for analysis in this sample). The most obvious interpretation is that drugs are useless and do nothing over and above psychotherapy. But the lack of random assignment should prevent us from leaping to that conclusion. Assume, for the moment, that therapists are canny about who needs drugs plus psychotherapy and who can do well with psychotherapy alone. The therapists assign those patients accordingly so appropriate patients get appropriate treatment. This is just the same logic as a self-correcting trajectory of treatment, in which techniques and modalities are modified with the patient's progress. This means that drugs plus psychotherapy may actually have done pretty well after all— 973 but only in a cannily selected subset of people. The upshot of this is that random assignment, the prettiest of the methodological niceties in efficacy studies, may turn out to be worse than useless for the investigation of the actual treatment of mental illness in thefield.It is worth mulling over what the results of an efficacy or effectiveness study might be if half the patients with a particular disorder were randomly assigned and were compared with half the patients not randomly assigned. Appropriately assigning individuals to the right treatment, the right drug, and the right sequence of techniques, along with individuals' choosing a therapist and a treatment they believe in, may be crucial to getting better. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. The Ideal Study The CR study, then, is to be taken seriously—not only for its results and its credible source, but for its method. It is largescale; it samples treatment as it is actually delivered in the field; it samples without obvious bias those who seek out treatment; it measures multiple outcomes including specific improvement and more global gains such as growth, insight, productivity, mood, enjoyment of life, and interpersonal relations; it is statistically stringent and finds clinically meaningful results. Furthermore, it is highly cost-effective. Its major advantage over the efficacy method for studying the effectiveness of psychotherapy and medications is that it captures how and to whom treatment is actually delivered and toward what end. At the very least, the CR study and its underlying survey method provides a powerful addition to what we know about the effectiveness of psychotherapy and a pioneering way of finding out more. The study is not without flaws, the chief one being the limited meaning of its answer to the question "Can psychotherapy help?" This question has three possible kinds of answers. The first is that psychotherapy does better than something else, such as talking to friends, going to church, or doing nothing at all. Because it lacks comparison groups, the CR study only answers this question indirectly. The second possible answer is that psychotherapy returns people to normality or more liberally to within, say, two standard deviations of the average. The CR study, lacking an untroubled group and lacking measures of how people were before they became troubled, does not answer this question. The third answer is "Do people have fewer symptoms and a better life after therapy than they did before?" This is the question that the CR study answers with a clear "yes." 974 The CR study can be improved upon, allowing it to speak to all three senses of "psychotherapy works." These improvements would combine several of the best features of efficacy studies with the realism of the survey method. First, the survey could be done prospectively: A large sample of those who seek treatment could be given an assessment battery before and after treatment, while still preserving progress-contingent treatment duration, self-correction, multiple problems, and self-selection of treatment. Second, the assessment battery could include well-normed questionnaires as well as detailed, behavioral information in addition to more global improvement information, thus increasing its sensitivity and allowing it to answer the return-to-normal question. Third, blind diagnostic workups could be included, adding multiple perspectives to self-report. At any rate, Consumer Reports has provided empirical validation of the effectiveness of psychotherapy. Prospective and diagnostically sophisticated surveys, combined with the well-normed and detailed assessment used in efficacy studies, would bolster this pioneering study. They would be expensive, but, in my opinion, very much worth doing. REFERENCES Consumer Reports. (1994). Annual questionnaire. Consumer Reports. (1995, November). Mental health: Does therapy help? pp. 734-739. Howard, K., Kopta, S., Krause, M., & Orlinsky, D. (1986). The doseeffect relationship in psychotherapy. American Psychologist, 41, 159-164. Howard, K., Orlinsky, D., & Lueger, R. (1994). Clinically relevant outcome research in individual psychotherapy. British Journal of Psychiatry, 165, 4-8. Lipsey, M., & Wilson, D. (1993). The efficacy of psychological, educational, and behavioral treatment: Confirmation from metaanalysis. American Psychologist, 48, 1181-1209. Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative studies of psychotherapies. Archives of General Psychiatry, 32, 995-1008. Muiioz, R., Hollon, S., McGrath, E., Rehm, L., & VandenBos, G. (1994). On the AHCPR guidelines: Further considerations for practitioners. American Psychologist, 49, 42-61. Seligman, M. (1991). Learned optimism. New York: Knopf. Seligman, M. (1994). What you can change & what you can't. New York: Knopf. Shapiro, D., & Shapiro, D. (1982). Meta-analysis of comparative therapy outcome studies: A replication and refinement. Psychological Bulletin, 92, 581-604. Smith, M., Glass, G., & Miller, T. (1980). The benefit of psychotherapy. Baltimore: Johns Hopkins University Press. December 1995 • American Psychologist
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Running head: CRITICAL REFLECTION ON EFFECTIVENESS OF PSYCHOTHERAPY

Critical Reflection on Effectiveness of Psychotherapy
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CRITICAL REFLECTION ON EFFECTIVENESS OF PSYCHOTHERAPY

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Critical Reflection on the Effectiveness of Psychotherapy
Is Psychotherapy Effective?
Introduction
In modern society, there is various personnel, who can provide psychotherapy treatment
such as the clinical social workers, psychiatric nurses, amongst others. People usually seek
psychotherapists when they are in a mental crisis. The families of the affected people have strong
believed that their loved ones will get better after seeking the services of qualified
psychotherapists. However, challenges arise in providing the best practice to the patients in the
sense that they may rely on records from randomized clinical trials without knowing whether the
assessments and tests used to treat them were effective or not. In this paper, I would reflect on
the effectiveness of psychotherapy. Ide...


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